PDF Potentially Inappropriate Medications in the Elderly

[Pages:11]Potentially Inappropriate Medications in the Elderly

Kasidy McKay, Pharm.D. Jora Sliwinski, Pharm.D. Idaho State University, Department of Family Medicine Pharmacotherapy Residents

Learning Objectives

Define the age at which a person is considered elderly Describe the physiologic changes that occur with increasing age Recognize over-the-counter and prescription medications that may be unsafe in the elderly Outline the differences between the STOPP/START and Beers criteria and how each can be used to improve patient safety and outcomes

Background

14% of U.S. population is 65 years or older

Up to 30% of total prescriptions are for this age group There were approximately 100,000 emergency hospitalizations for adverse drug events in U.S. adults 65 or older between 2007-2009 Elderly account for about half of hospitalizations due to adverse drug events The percentage of elderly in the U.S. population is expected to increase (nearing 20%) in the next 10 years as the baby boomers age.

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Background Continued

Physiological changes put the elderly at increased risk of adverse events Guidelines exist to assist providers in prescribing medications safely in the elderly Potentially inappropriate medications (PIMs) can lead to adverse drug events and hospitalizations

Definitions: Elderly

Medical definition is anyone aged 65 years and older "elderly" "geriatric" "seniors"

Definitions: Potentially Inappropriate Medications (PIMs)

Inappropriate prescribing when there is a safer alternative Dose too low/high Use at higher frequency or duration than recommended Two drugs in same class/same mechanism of action Known drug-drug interaction Known drug-disease state interactions Not prescribing a needed medications for ageist or irrational reasons

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Physiological Changes that Occur with Aging

Decreased kidney function Decreased muscle mass

Increase in adipose tissue Decreased liver function

Decrease in liver mass and blood flow Decrease in liver enzyme production Decreased bone mass Decrease in serum albumin

Guidelines for Medication Use in Elderly Patients

Beers Criteria: Initially published by Dr. Mark Beers in 1991 Updates in 1997, 2002, and 2012 For identifying potentially inappropriate medications (PIMs) in older adults Updated by the American Geriatrics Society Catalogues medications that cause adverse events in older adults due to their pharmacologic properties and the physiologic changes of aging

Guidelines for Medication Use in Elderly Patients

START Criteria (Screening Tool to Alert doctors to Right Treatment) 22 "rules" related to common prescription omissions for geriatric population Alerts providers to medications that the patient should be taking based on disease states

STOPP Criteria (Screening Tool of Older Person's potentially inappropriate Prescriptions)

65 item list regarding drug:drug interactions, drug:disease state interactions, therapeutic duplications, drugs that increase risk of cognitive deterioration Alerts providers to medications that are more likely to cause adverse events in the elderly patients

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Guidelines for Medication Use in Elderly Patients

START/STOPP was created by members of the Cork University Hospital Department of Geriatric Medicine and University College Cork, School of Pharmacy in Ireland. START: created to assess acts of prescribing omission STOPP: created, in part, for use outside the U.S.Allows for more exceptions based on patient factors vs. Beer's.

Differences Between Guidelines

Beers Criteria

No component to address medications that the patient should be taking based on disease state Half of listed drugs are not identified in European Drug Index

Beers criteria hard to apply outside of US May be more difficult to interpret and apply clinically compared to START/STOPP

Differences Between Guidelines

START/STOPP

STOPP identifies more potentially unsafe medications than Beers Includes DDI and drug-disease interactions Designed for all clinical settings Addresses duplicate drug class prescriptions Organized according to relevant physiological systems Recognizes specific high risk populations Reflects current prescribing practice

Includes both American and European medications Provides more guidance on what's appropriate, what's not and why

*START/STOPP are typically grouped together

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Drawbacks of the Guidelines

No clear evidence to prove Beers and START/STOPP reduce morbidity, mortality or cost Does not replace clinical judgment Always look at the whole picture while considering:

Patient's history Chronic diseases Functional status Prognosis (patient's life expectancy and quality of life) Patient's perceptions and preferences

Technician Point of View

Community Technician Familiar with patients and their medication history and disease states Sells OTC medications

Hospital Technician Prepares medications for patients on the floor Can recognize doses/drugs that may not be safe in the elderly

Technicians are in a great position to "flag the pharmacist" when potential interactions are encountered or when something doesn't seem right

OTC Medications to Think About

1st generation anticholinergics NSAIDs Aspirin Cimetidine Proton pump inhibitors (PPI) Laxatives/Stool softeners Decongestants

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1st Generation Anticholinergics

Diphenhydramine (Benadryl?), chlorpheniramine (ChlorTrimeton?)

Do not use for more than 1 week Increased risk of: sedation, falls, constipation, urinary retention, worsened dementia Look out for combo products-especially sleep aids

Disease States to Question Use

BPH

Constipation

Urinary retention

Fall History

Dementia

NSAIDs

Ibuprofen (Motrin?), Naproxen (Aleve?) Increased risk of: Stomach bleed, worsening high blood pressure, worsening heart failure

Patient Populations to Question Use

Risk/history or stomach bleed Poor kidney function

High blood pressure

Osteoarthritis > 3 months use

Heart failure

Long-term use for gout

Aspirin

Increased risk of: stomach bleeding Enteric coated decreases stomach upset/damage If the patient has a history of stomach ulcer: use with a proton pump inhibitor or H2 blocker

Patient Populations to Question Use

Patients taking Coumadin

Stomach ulcer history

Daily dose >150 mg

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Cimetidine

Cimetidine (Tagamet?) Has several potential drug interactions Not often stocked in pharmacies Alternatives are famotidine (Pepcid?) and ranitidine (Zantac?)

Patient Populations to Question Use

With Coumadin

With Plavix

With Celebrex

Liver Impairment

Proton Pump Inhibitors (PPI's)

Omeprazole (Prilosec?), lansoprazole (Prevacid?) Increased risk of: osteoporosis, pneumonia, C. diff diarrhea

Concerns when used at full dose for > 8 weeks Not indicated for long-term treatment of peptic ulcer disease or GERD

Patient Populations to Question Use

GERD

Peptic ulcer disease

Osteoporosis

Antibiotic use

Laxatives/Stool Softeners

Countless varieties Several medications can cause constipation Frequent purchase of stool softeners/laxatives should be addressed

Chronic opioid use: patient should have a set "bowel regimen" usually docusate BID and senna daily

Patient Populations to Question Use

Opioid pain medication

OTC antihistamine use (i.e., diphenhydramine

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Decongestants

Pseudoephedrine (Sudafed?), Phenylephrine (Sudafed PE?)

Increased risk of: insomnia, elevated blood pressure Considered stimulants

Disease States to Question Use Uncontrolled Blood Pressure Insomnia

Patient Case:

Mrs. Smith, 83 y/o, comes to the pharmacy counter to pick up her monthly prescriptions of warfarin 7.5mg, lisinopril 10mg, simvastatin 20mg, metformin 500mg, and ASA 81mg. She tells you that her arthritis has been "acting up" and asks if Aleve or Advil would work well for her.

What medications are of concern for Mrs. Smith? When alerting your pharmacist prior to counseling, what would you point out?

Patient Case:

Mrs. Green, 84 y/o, comes into the pharmacy to pick up her warfarin 2.5mg for atrial fibrillation. While talking with you, she tells you she just started seeing a new doctor. On her last 3 office visits, her BP has been 164/92, 186/91, and 172/94, respectively. According to START, would you alert your pharmacist to consult with her PCP about any HTN medications?

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